Form Ri-Eft - Authorization Agreement For Electronic Funds Transfers

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STATE OF RHODE ISLAND
DEPARTMENT OF ADMINISTRATION
DIVISION OF TAXATION
ONE CAPITOL HILL
PROVIDENCE, RI 02908-5800
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERS
FEDERAL IDENTIFICATION NUMBER:
___ ___ ___ ___ ___ ___ ___ ___ ___
TYPE OF TAX:
[ ] ALCOHOLIC BEVERAGE IMPORT SERVICE FEE
[ ] HOTEL TAX
[ ] BANK EXCISE
[ ] INSURANCE PREMIUMS TAX
[ ] CIGARETTE STAMP TAX
[ ] LITTER – BEVERAGE CONTAINER
[ ] CORPORATION TAX
[ ] PUBLIC SERVICE GROSS EARNINGS
[ ] GASOLINE TAX – MOTOR FUEL
[ ] SALES/USE TAX
[ ] HEALTH CARE – GROUP HOMES
[ ] UNIFORM OIL RESPONSE & PREVENTION FEE
[ ] HEALTH CARE – NURSING HOMES
[ ] WITHHOLDING TAX
Sections A & B below must be completed by all taxpayers
A. COMPANY DATA
COMPANY NAME: ___________________________________________________________________________________________
D/B/A: ______________________________________________________________________________________________________
ADDRESS: ___________________________________________________________________________________________________
CITY: ____________________________________ STATE: ___ ___ ZIP CODE: ___ ___ ___ ___ ___ - ___ ___ ___ ___
TELEPHONE NO: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
B. CONTACT PERSON(S):
PRIMARY EFT CONTACT PERSON:
NAME: ___________________________________________TITLE: _____________________________________________________
ADDRESS: ___________________________________________________________________________________________________
CITY: ____________________________________ STATE: ___ ___ ZIP CODE: ___ ___ ___ ___ ___ - ___ ___ ___ ___
PHONE NO: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ EXT. _________ FAX NO: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
EMAIL ADDRESS: ____________________________________________________
SECONDARY EFT CONTACT PERSON:
NAME: ___________________________________________TITLE: _____________________________________________________
ADDRESS: ___________________________________________________________________________________________________
CITY: ____________________________________ STATE: ___ ___ ZIP CODE: ___ ___ ___ ___ ___ - ___ ___ ___ ___
PHONE NO: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ EXT. _________ FAX NO: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
EMAIL ADDRESS: ____________________________________________________
_______________________________________________________________________
____________________________
Signature of Owner, Partner or Officer of Corporation
Date
FORM RI-EFT
REVISED: JUNE 2003

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